Healthcare Provider Details

I. General information

NPI: 1811353311
Provider Name (Legal Business Name): TOTAL NUTRITION SOLUTIONS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2262 119TH PL
BLUE ISLAND IL
60406-1123
US

IV. Provider business mailing address

2262 WEST 119TH PL
BLUE ISLAND IL
60406-1123
US

V. Phone/Fax

Practice location:
  • Phone: 708-385-0882
  • Fax:
Mailing address:
  • Phone: 708-385-0882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number164003956
License Number StateIL

VIII. Authorized Official

Name: MRS. SANDRA MARIE PHILLIPS
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 630-865-2529